chest pain

Typical Characteristics and Diagnostic Studies of Chest Pain > Chest Pain form CPS

Initial diagnostic studies

• Focused history of chest pain

• Targeted exam:

  • VS (incl. BP in both arms);
  • gallops, murmurs, rubs;
  • signs of vascular dis. (carotid/femoral bruits, ↓ pulses) or CHF;
  • lung & abd. exam;
  • chest wall for reproducibility

• 12-lead ECG:

  • obtain w/in 10 min;
  • compare to priors & obtain serial ECGs;
  • consider posterior leads (V7–V9) if hx c/w ACS but stnd ECG unrevealing or ST ↓ V1–V3 & pain refractory

• Troponin

• CXR; other imaging (echo, PE CTA, etc.) as indicated based on H&P and initial testing

Initial approach (Circ 2021;144:e368)

• R/o life-threatening causes (ACS, PE, AoD, myopericarditis, etc.)
• If possible ACS, risk stratify w/ clinician decision pathway (clinical factors + ECG + Tn)
• Low prob ACS (eg, H&P unconcerning, ⊖ ECG & Tn): d/c to home; risk factor mgmt
• Intermed prob ACS (neither low nor high clinical risk, ± borderline Tn): ✓ TTE and
  • If no known CAD → CCTA or stress (former ↓ LOS c/w fxnal testing; NEJM 2012;366:1393)
  • If recent mildly ⊕ stress or known non-obstructive CAD → CCTA
  • If obstructive but not high-risk CAD → stress test
  • If recent mod-severely ⊕ stress or high-risk CAD (LM, prox LAD, MVD) → invasive angio
• High prob ACS (eg, ECG Δs, ⊕ Tn, new ↓ LVEF): invasive coronary angiography
• Pts w/ acute CP: CCTA vs. stress testing → ↓ time to dx & LOS (less so in era of hsTn), but ↑ probability of cath/PCI (NEJM 2012;366:1393 & 367:299; JACC 2013;61:880)

Conclusion

• If possible ACS, risk stratify w/ clinician decision pathway (clinical factors + ECG + Tn)
• Low prob ACS (eg, H&P unconcerning, ⊖ ECG & Tn): d/c to home; risk factor mgmt
• Intermed prob ACS (neither low nor high clinical risk, ± borderline Tn): ✓ TTE and
  • If no known CAD → CCTA or stress (former ↓ LOS c/w fxnal testing; NEJM 2012;366:1393)
  • If recent mildly ⊕ stress or known non-obstructive CAD → CCTA
  • If obstructive but not high-risk CAD → stress test
  • If recent mod-severely ⊕ stress or high-risk CAD (LM, prox LAD, MVD) → invasive angio

Further reading

• Cardiology - Congestive Heart Failure - Fast Facts NEJM Resident 360 date: 2023-02-23 18:31
• Cardiology - Pericardial Disease and Myocarditis - Fast Facts NEJM Resident 360 date: 2023-02-23 18:32
• Cardiology - Valvular Disease - Fast Facts NEJM Resident 360 date: 2023-02-23 18:31
• Cardiology - Arrhythmias - Fast Facts NEJM Resident 360 date: 2023-02-23 18:31
• Cardiology - Coronary Artery Disease and Acute Coronary Syndrome - Fast Facts NEJM Resident 360 date: 2023-02-23 18:32